CATARACT

What is a cataract?

A cataract is the term given to any opacification of the natural crystalline lens in the eye. Most cataracts develop slowly and they increasingly impair vision over time. There is no cure for cataracts. They can only be removed by surgery and at the same time a small lens implant is placed inside the eye to focus the light on your retina.

How do I know that I have a cataract?

Cataracts mostly develop slowly, and in both eyes, so you may not be aware that you have them. You might have noticed increasing difficulty with visual tasks such as reading and driving, especially in more dimly lit environments. You might have reduced contrast sensitivity or symptoms of glare. Spectacles will not fix the cataract and you may feel dissatisfaction with a new pair in the presence of cataracts. This is common.

Do I have to have cataract surgery?

Cataracts do not damage the eye in normal situations and deciding to have a cataract operation is a decision you will make in conjunction with Dr. Kert. It is quite safe to postpone cataract surgery if you are unsure about proceeding or feel that the cataract is not troubling you. With a cataract in your eye your vision will decline slowly over a period of several years and Dr. Kert will ask you to return within that time for a review. Your other option is to proceed with cataract surgery, an operation to remove the cloudy opacified cataract and replace it with a clear lens implant.

There is no medicine or natural remedy that will remove or dissolve a cataract.

What will happen to me before cataract surgery?

You will have a meeting with Dr. Kert and she will discuss your cataracts with you. You will then have some measurements done on your eyes to determine what size lens to implant in your eye. We usually do measurements on both eyes at the same time. Please stay on all your normal medications pre-operatively including aspirin and warfarin. You will be given information about the timing of surgery. Most people have one eye operated on, followed by the second eye 2-3 weeks later.

Cataract surgery is a ‘once in a lifetime’ event and does not need to be repeated. The lens implant lasts a lifetime and is not biodegradeable.

What will happen to me on the day of surgery?

Cataract surgery is performed in the day surgery unit at St Andrew’s Toowoomba Hospital. While there is no need to stay overnight, some patients who live alone may choose to spend one or two nights in hospital. Usually you will be in the day hospital unit for about three hours in total. The surgery takes 20-30 minutes and is performed under local anaesthetic with sedation or twilight anaesthetic. You will be sleepy during the operation, but will feel no pain or discomfort. It is normal to feel a little anxious before the operation however we will make sure you are comfortable and relaxed when you come to have your surgery. After surgery you will go home with a clear plastic shield over the eye and you will have instructions regarding eye drops. It is expected that the eye will feel a little bit gritty or mildly uncomfortable for a day or so after surgery.

Complications of Cataract Surgery

Cataract surgery is well tolerated. Most people will have a 99% chance of seeing better following surgery. This will not be the case if you have a pre-existing eye condition such as macular degeneration or glaucoma and Dr. Kert will alert you to this if it applies to you.

One in a hundred (1/100) patients may experience a minor complication that is inconvenient and may require further non-routine intervention such as a second operation, prolonged post operative eyedrops or further non-routine management that is annoying but not dangerous. One in a thousand (1/1000) people will have a major complication such as infection, bleeding or a major intra-operative complication. Everything possible will be done to minimise the chance of complications. If you have a serious complication you will most likely need a second operation possibly in Brisbane and sometimes involving a stay in hospital for a week or two while your eye recovers. You can rarely become blind or lose your eye following cataract surgery, but this is extremely rare. This is the reason that your cataract surgery will be performed one eye at a time.

Please feel free to contact Dr. Kert’s rooms at any time if you have further questions.

pterygium

What is a pterygium?

A pterygium is a small fleshy growth of tissue on the front surface of the eye. It is usually raised and red. It can increase in size over time, and spread across onto the cornea. It occurs in response to sunlight exposure, usually acquired during childhood and early adulthood.

What symptoms do pterygiums cause?

Because pterygia are raised, they can cause ocular irritation and symptoms of dryness or foreign body sensation.

They can result in blurry vision by destabilising the tear film, or through induced astigmatism (by deforming the front of the eye).

They can also become very red and unsightly and cause sufferers distress through their appearance.

Pterygiums never self-correct and over time, continue to grow towards the pupil.

How can I treat my pterygium?

You can elect to manage your pterygium conservatively by regularly applying ocular lubricants. This will help alleviate the irritation. Unfortunately your pterygium will not regress with eye-drops alone.

Surgical removal followed by placement of an autoconjunctival graft is the definitive treatment of pterygium. Dr. Kert will discuss this with you, and together you will decide whether or not to proceed.

Reasons to have your pterygium removed

Reasons to have your pterygium removed include:

Documented growth. As the pterygium grows, it will cause permanent scarring which is a concern if it is progressing across your cornea. Growth of the pterygium may in time cause permanent visual loss.

Redness that is becoming intolerable.

Pain and discomfort that is becoming intolerable.

What will happen to me if I have pterygium surgery?

Pterygium removal is conducted under assisted local anaesthetic or sometimes under general anaesthesia. The operation usually takes 45-60 minutes and you will feel no pain or discomfort during the procedure.

You will go home with oral pain relief, and an eye pad covering the eye. You do not usually need to stay overnight in the Hospital.

Whilst wearing an eye pad you must not drive a vehicle and you must take care walking down stairs and negotiating gutters.

Dr. Kert will usually see you one week after your operation.

After your operation, your eye will feel very sore for 3-4 days. It will be watery, feel like gritty sand is inside your lids, and your eye will be very sensitive to light.

There will be eye drops to place in your eye after surgery for 8 weeks. We recommend you take one week off from work/normal duties if possible.

Your eye will be red for 6-8 weeks after surgery.

What are the risks of surgery?

Like any operation, there are risks. Fortunately these are rare.

There is a 1/20 chance of the pterygium growing back after surgery and this usually happens during the healing phase within the first 6 months. If you have a recurrence you may require a second operation. It is important that you continue the drops as recommended and stay out of the sun as much as possible to minimise the chance of recurrence. Wearing a hat and sunglasses when you go outside can help prevent the pterygium from returning.

Other much rarer risks include infection, bleeding, damage to the vision.

Please feel free to speak with Dr.Kert if you have any further questions prior to your operation.

Macula

What is the macula ?

The macula is the central part of the retina. It is located directly behind the pupil at the very back of the eye. Light entering the eye is focused on a point called the fovea at the centre of the macula.

The macula is the most sensitive part of the retina as it sub-serves detailed vision and colour vision. You read, recognise faces, thread a needle, drive a car and watch TV with your macula. Diseases of the macula can affect all of these functions.

The commonest symptom experienced with macular pathology is metamorphopsia, where straight lines appear wavy or bent. People suffering from diseases of the macula can also complain of difficulty with near visual tasks , such as reading due to a black or grey area in the centre of the vision. Some patients with macular disease will report blurred vision . Unfortunately, in most cases spectacle correction will not assist in making the vision clearer.

You will be provided with information about these tests prior to proceeding.

When you come in to the clinic your macular condition will be assessed. Dr Kert will then discuss your condition with you and in many cases offer you options for treatment on the same day. These most likely will include a recommendation to undertake intravitreal therapy. This is a procedure by which a therapeutic medicine is injected via a very tiny needle into the back of the eye (vitreous cavity) to treat swelling of the macula (macula oedema). This procedure is carried out in the fully equipped treatment room under sterile conditions. It is done under topical local anaesthetic and usually takes a few minutes to complete. It is common to experience some pressure and slight discomfort momentarily during the procedure. It is surprisingly well tolerated and Dr Kert and her staff will guide you through this experience in a gentle and professional manner. We are always happy to take the time to explain the procedure to you and answer all your questions along the way .

What treatments are available?

Treating macular disease usually entails a long-term partnership between the patient and treating doctor . Therapy for macular disease can be burdensome for patients and relatives alike. In many cases treatment will need to be persistent, periodic and sometimes last many years. At Darling Downs Eye we understand this and endeavour at all times to care for you and support you in maintaining therapy long term. We know from scientific research that patients who persist with recommended therapy have the best visual outcomes in the long term.

We always offer the latest evidence-based treatments to maximise your vision and will discuss alternative treatment options where they exist .

We can enrol you in support programs as indicated and also encourage access to low visual aides and assessments as necessary.

Here at Darling Downs Eye , Dr Kert and her team will hold your hand as together we negotiate your macular disease.

gLAUCOMA

What is glaucoma?

Glaucoma is the name given to a group of eye diseases in which the optic nerve at the back of the eye is slowly damaged. In most people this damage is due to an increased pressure inside the eye – a result of blockage of the circulation of fluid in the eye or blocked drainage. In other patients the damage may be caused by poor blood supply to the vital optic nerve fibres, a weakness in the structure of the nerve, or a problem in the health of the nerve fibres themselves.

Over 300,000 Australians have glaucoma. While it is more common in older Australians, it can occur at any age.

As our population becomes older, the proportion of glaucoma patients is increasing.

Usually the condition is painless.

Glaucoma Facts

Glaucoma is the leading cause of irreversible blindness worldwide.

One in 10 Australians over 80 will develop glaucoma.

First degree relatives of glaucoma patients have an 8-fold increased risk of developing the disease.

At present, 50% of people with glaucoma in Australia are undiagnosed.

Australian health care cost of glaucoma in 2005 was $342 million.

The total annual cost of glaucoma in 2005 was $1.9 billion.

The total cost is expected to increase to $4.3 billion by 2025.

The dynamic model of the economic impact of glaucoma enables cost-effectiveness comparison of various interventions to inform policy development.

Source: Tunnel Vision. The economic impact of Open Angle Glaucoma, Centre for Eye Research Australia, 2008

What are the symptoms of glaucoma?

Chronic (primary open-angle) glaucoma is the most common type. It is painless.
Damage progresses very slowly and destroys vision gradually, starting with the side vision. Early on the person remains unaware of any problem. Glaucoma may only be noticed when a majority of nerve fibres have been damaged, and a large part of vision has been destroyed. This damage is irreversible. It is progressive and usually relentless. Treatment cannot recover what has been lost. Treatment can arrest, or at least slow down the damage process. That is why it is so important to detect the problem as early as possible, to be able to start treatment with as little damage to the vision as possible.

Who is at risk?

Although anyone can get glaucoma, some people have a higher risk, those with

A family history of glaucoma

Diabetes

Migraine

Short sightedness (myopia)

Long sightedness (hyperopia)

Eye injuries

Past or present use of cortisone drugs (steroids)

What is the usual management of glaucoma?

Most patients will see Dr Kert every six months for a glaucoma assessment. The assessment will involve checking the vision, the intraocular pressures and looking at the optic disc. Other tests are usually performed such as visual fields, OCT imaging of the optic disc and glaucoma parameters and fundus photography.

At each visit, Dr Kert will assess the progression of your glaucoma and may make changes to your glaucoma treatment. The treatment and surveillance of the condition are life long as there is no cure for glaucoma.

Treatment for Glaucoma

Topical medication (eye drops)

Eye drops are usually the first line management of glaucoma. Instructions of how to instil eye drops can be found here.

Selective Laser Trabeculoplasty, or SLT

Selective Laser Trabeculoplasty, or SLT is a form of laser surgery that is used to lower intraocular pressure in glaucoma. It is used when eye drop medications are not lowering the eye pressure enough or are causing significant side effects. It may sometimes be used as initial treatment in glaucoma. SLT has been in use for 12 years in Australia and around the world.

3. Minimally Invasive Glaucoma Surgery ( MIGS)

MIGS refers to a group of tiny devices or implants that can be surgically placed inside the eye to assist in the drainage of fluid to compartments outside the eye. The device is carefully placed inside the eye during a surgical operation in the operating theatre . It increases the outflow of fluid from the eye ( aqueous) thereby reducing the intra-ocular pressure.

3. Trabeculectomy

A trabeculectomy is a more invasive surgical operation that works to lower the intraocular pressure. It is conducted in the operating theatre and is generally reserved for the more serious types of glaucoma where the intraocular pressures cannot be controlled by more conservative means.

Selective Laser Trabeculoplasty, or SLT

Who is a candidate for SLT?

Patients who have open-angle glaucoma (the drainage system in the front part of the eye is open) and are in need of lowering of their intraocular pressure (IOP) are eligible for the procedure. Dr Kert will make the final determination if you are a candidate.

How does it work?

Laser energy is applied to the drainage tissue in the angle of the eye. This starts a chemical and biological change in the trabecular meshwork tissue . This allows the aqueous fluid to drain out of the eye more effectively. This eventually results in lowering of intraocular pressure. It may take 1-3 months for the laser to effect a lowering of the eye pressure.

Why is it called Selective?

The type of laser used has minimal heat energy absorption because it is only taken up by selected pigmented tissue in the eye. Sometimes it is referred to as a ‘cold laser.’ Because of this, the procedure produces less scar tissue and has minimal pain.

What are the risks of SLT?

One key aspect of SLT is a favourable side effect profile, even when compared with glaucoma medications. Post-operative inflammation is common but generally mild, and treated with observation or eye drops or an oral non-steroidal anti-inflammatory drug. There is an approximately 5% incidence of intraocular pressure elevation after laser, which can be managed by glaucoma medications and usually goes away after 24 hours.

How effective is SLT?

SLT lowers the intraocular pressure by about 30% when used as initial therapy in most patients. This is comparable to the intraocular pressure lowering of the most powerful and commonly used class of glaucoma medication (prostaglandin analogs). This effect may be reduced if the patient is already on glaucoma medications.

How long does the effect last?

The effect will generally last between 1-5 years, and in rare cases, longer than that. If it does not last at least 6-12 months, it is usually not considered successful.

What happens if it wears off?

If SLT is effective at lowering intraocular pressure but this wears off over several years, the procedure can be repeated but the second treatment may not be as effective as the first and may not last as long. If SLT is not initially successful, repeat treatment is not likely to be effective. Alternatively, glaucoma medication can be used if the effect wears off over time.

What happens if it doesn’t work?

If SLT fails to lower the intraocular pressure, then the glaucoma is treated by other means such as medications or Minimally invasive glaucoma surgery ( MIGS) or conventional glaucoma surgery such as trabeculectomy. The laser does not affect the success of these other types of treatment.

What is the cost?

Since the procedure is an accepted glaucoma treatment, and is approved, it is covered by Medicare. The cost will be discussed with you prior to proceeding. The Medicare Safety Net can assist you in covering most of the out of pocket expenditure.

Will I still need to use glaucoma medications?

Some patients can be controlled with just laser treatment. Others require additional intraocular pressure lowering and may therefore need to use glaucoma medication as well. Think of the SLT as equivalent to one glaucoma medication. Just as some patients will require more than one glaucoma medication to control their intraocular pressure, some may also require laser plus one or more glaucoma medications. It is important to remember that SLT is not a cure for glaucoma, just as medication and surgery are also not cures for glaucoma .

Glaucoma is a lifelong condition with no cure . Management requires life long follow up to ensure each patient achieves the best possible vision in the later years .

Whatever method is used to treat glaucoma, continuing appropriate follow up and testing at Darling Downs Eye is critical.

If you have any further questions feel free to call the team at Darling Downs Eye to discuss further.

Trabeculectomy

Why has my doctor recommended this operation?

Glaucoma may get worse if the pressure inside the eye is not low enough. Trabeculectomy is recommended when eye drops are not controlling the pressure and there is a significant risk that glaucoma is going to cause further damage to your sight.

What is trabeculectomy?

A trabeculectomy is an operation to make the pressure lower inside the eye. It involves making a new channel in the white wall of the eye (sclera), through which fluid flows out into a space underneath the outer layer of the eye (conjunctiva). A successful trabeculectomy creates what we call a ‘bleb’, a small elevation which is usually covered by the upper eyelid.

What anaesthetic is used?

Trabeculectomy is usually done as a day case under general anaesthetic. It can also be performed under local anaesthetic or eye block with sedation.

What happens after the operation?

Frequent follow-up is required in the first few weeks and months after this operation. All patients need to be reviewed the day after surgery then, if all is well, a week later and again one to three weeks after that. The exact timing of these and future reviews depends on how the eye is settling down, and more frequent visits are quite often required. The first few weeks after the operation are very important for checking the eye and for carrying out adjustments. Most of these adjustments are minor and will be done as part of the outpatient visit. It is best to avoid planning any holidays within two months after the operation. If you already have a holiday planned, you do need to discuss this with Dr Kert , and schedule the surgery appropriately.

What will my vision be like?

It is common for the eye that has had the surgery to be quite blurred for a few weeks, sometimes longer. There is no need to change your glasses straight away, but some patients will benefit from updating their glasses sooner than they normally would, although it is best to wait for three months while things settle. You can resume driving after a few days (if this applies to you) if your vision is sufficient for you to meet the legal requirements. Trabeculectomy does not improve vision – its purpose is to prevent sight loss in the future.

What can I and can’t I do after trabeculectomy?

Returning to work Most people can return to office-based work two weeks after the operation though sometimes longer is needed. It is usually wise to wait at least a month before resuming physically strenuous work or work in a dusty/dirty environment. Dr Kert will advise you in more detail about this at your postoperative checks.

Activity You can use your eyes for reading, television, computers etc as soon as you wish – this will not harm your eye. Gentle exercise (walking) is fine, but you should expect to avoid strenuous exercise (running, ball sports, fitness workouts), or lifting heavy objects for at least a month after the operation. Swimming or immersing the eye should be avoided for at least one month – please ask at your check-up if you wish to resume swimming. It may be useful to keep the clear shield on your eye, or wear glasses for the first week after the operation, for the protection that it offers.

How successful is trabeculectomy?

The operation helps lower the pressure in the eye in about 90% of cases, and most patients will not need glaucoma drops in the eye that has had the operation. A lower pressure is beneficial to nearly all patients with glaucoma, but glaucoma can still progress – in some cases even after a ‘successful’ trabeculectomy.

Trabeculectomy can fail over time and may need adjustments such as ‘ needling ‘ procedures to break down adhesions and scar tissue as they form. This is to ensure outflow is maintained.

What are the risks and complications of trabeculectomy?

We always need to consider the risks as well as the potential benefits before going ahead with an operation. If this surgery has been recommended then Dr Kert will have judged that the risk to your sight from glaucoma (without the operation) is greater than the risks of the operation itself. For most patients trabeculectomy achieves a lower pressure without any significant problems; however, all operations do have some risks and for trabeculectomy these include:

Reduced vision This is very common in the first two weeks, due to swings in the pressure

Minor bleeding inside the eyeThese typically settle within the first few weeks. Some patients (five to eight percent) may have some degree of permanently reduced vision after the operation. Loss of all vision in the eye due to the surgery itself is very unusual, but as with all intraocular surgery can very rarely occur.

Discomfort This usually settles within a few weeks, but some patients experience long-term discomfort. These symptoms are usually mild and can be controlled with artificial tears.

Increased likelihood of cataract This is quite common within five years. If it does occur, it can be treated in the normal way. In some patients a trabeculectomy works less well if a cataract operation is performed subsequently. Dr . Kert may elect to perform cataract surgery prior to the trabeculectomy.

Infection and loss of vision in the eye There is a small risk of infection after any eye surgery including trabeculectomy. Additionally, after trabeculectomy there is a permanently-increased risk of infection getting inside the eye. The risk is small, roughly one in a thousand.

Further surgery may be required to make the operation succeed, or to correct low pressure. It is not unusual for an additional procedure of some sort to be required – usually this is a much shorter procedure than the trabeculectomy itself ( such as a bleb needling procedure )

Further information.

If you have any further questions feel free to call the team at Darling Downs Eye to discuss further.

eyelids

Eyelid surgery is usually performed to restore the normal anatomical location of the eyelid.

This is important so that the function of the eyelid can be optimised. It may involve tightening of the eyelid, turning the eyelid out or in, elevating or lowering the height of the eyelid, removing excess skin or applying a skin graft in situations where the skin is too short. Eyelid surgery is usually required to correct normal ageing changes in the skin tissue such as loss of elasticity and tone in eyelid supporting tissues.

Sometimes eyelid surgery is also required to remove a lump or a skin cancer. In this case, surgery is required to remove the lesion completely and then to reconstruct the eyelid to return it to the correct anatomical position and function.

All eyelid surgery is well tolerated as the face has a very good blood supply.

It is mostly performed as a day surgery operation in the hospital with the assistance of a team of doctors and nurses. Some eyelid procedures can also be performed in our well equipped treatment room in the clinic. If performed in hospital, it is usually under local anaesthetic with sedation. You will be aware that you are in the operating theatre but will feel very relaxed, comfortable, and sleepy.

Afterwards your eyelid may have a pad covering it, applying pressure. Please leave all pads intact until instructed otherwise. Ice is often applied after surgery to reduce swelling . You may be instructed to continue the ice packs to the eye lids at home following discharge.

You will need to have someone accompany you home after the operation as you will not be legally fit to drive. You will have an instruction booklet with you .

It is normal to experience some pain overnight and for a day or two after the operation.

Swelling is common and a normal part of the healing process. You may be asked to apply ice to the surgery area on the day of the operation and at home.

As with all surgery, there are risks associated with eyelid surgery.

At every stage, everything is done to minimise the risks to you, but occasionally things can go wrong. These risks include:

Infection: especially if you have existing inflammation.

Bleeding: especially if you have been on aspirin, warfarin or other blood thinners. Dr. Kert will ask you to stop these well before your surgery if possible. Sometimes we are not able to stop anticoagulant medications and in those cases, the risk of bleeding is greater.

Incomplete removal of tumour necessitating more surgery.

Scarring occurs following all surgery. Every attempt is made to minimise the scar so it is almost unnoticeable.

Asymmetry in the lid height or function between the two eyes.

Failure of the operation to achieve the desired result, for example, less watering, improved comfort etc.

If any of these undesired outcomes occur, you may need a second operation to enhance the outcome.

Please feel free to contact Dr. Kert at any time to discuss any further questions you may have.